Rapid Assessment of Sexual and Reproductive Health and HIV Linkages: Swaziland

This summary highlights insights gained through an assessment process conducted in Swaziland to better understand the linkages between sexual and reproductive health (SRH) and HIV/AIDS. The assessment was part of a multi-country initiative conducted using an assessment tool developed in 2009 by the International Planned Parenthood Foundation, United Nations Population Fund, World Health Organisation, the Joint United Nations Programme on HIV/AIDS, GNP+, the International Community of Women with HIV/AIDS, and Young Positives. This tool was created to support national assessments of the linkages between SRH and HIV at the policy, systems, and services levels and is being used within countries to determine priorities and shape national plans and frameworks for scaling up and intensifying linkages.

The report outlines the process of assessment in Swaziland and then highlights the findings and challenges at policy, systems, and services level. It also looks at lessons learned from the assessment process and the research results, and offers steps going forward. Recommendations based on the assessment are cited at the beginning of the report.

The assessment is based on a literature review and interviews with service providers, such as health care workers, and clients of both SHR and HIV services. Interviews related to HIV and SRH policy were also conducted with government officials and donor agencies.

Findings
At a policy level, the review showed that there was government commitment to integrate services, however, respondents also "expressed concern about the lack of specific national policies on SRH and HIV integration". As stated in the report, "about half of the respondents felt that integration would improve the efficiency of service delivery. Many also said it would reduce stigma and discrimination. But there were concerns about increased costs for staff development and recruitment, space, equipment and supplies."

At a systems level, the report looks at partnerships; planning; human resources and capacity building; logistics supply and laboratory support; and monitoring and evaluation. To mention just some of the findings, the assessment found that "responses to SRH and HIV remain largely vertical – with separate planning, budgeting and implementation processes." For human resources, it was found that the "supervision system at the services level is reported to minimally promote integration" and concerns were raised that, although training materials integrated HIV and SRH, these may be outdated.

At a services level, the report looks at service provider perspectives and service user perspectives. About half of the service provider respondents felt that "integration would improve the efficiency of service delivery" and "many also said it would reduce stigma and discrimination." However, there were concerns about increased costs for staff development and recruitment, space, equipment and supplies. The majority of service users said "they preferred to receive services from the same facility and same provider for both SRH and HIV. Their reasons included: ‘one stop’ access; convenience; confidentiality; relationship building with providers; and reduced cost and time." They identified the following weaknesses of SRH and HIV integrated services: "non-availability of a particular service at a ‘one stop’ facility; and challenges with involving men."

Recommendations
Based on the findings of the assessment, the report offers recommendations for policy, systems, service delivery, as well as recommendations from the client perspective. The following are just a few that are relevant when looking at education, information, and communication needs:
At a systems level:

• "There should be planned – and systematically structured, monitored, evaluated and coordinated – continuing education for service providers to support them to effectively provide specific SHR and HIV services, such as paediatric HIV and youthfriendly services."
• "Pre-service education institutions should do needs assessments to establish gaps and review the curricula in line with SRH and HIV linkages."
• "Supervision guidelines and protocols should be developed and supervisors trained and appropriately supported to conduct supportive supervision."
• "There is an urgent need for research to enhance programming for male involvement."

At a service delivery level:

• The report states that "Interventions that successfully implement training of service providers in knowledge and attitudes lead to better SRH and HIV service provision. As such, adequate staffing and training should be provided to effectively implement linkages and provide good quality services."
• "Service providers should be properly trained and oriented in the provision of services for special populations, such as men who have sex with men (MSM), sex workers, factory workers, mobile populations, people that use drugs, and young people."
• From the client perspective, the report states that "integrated and linked service provision was considered by most clients to be convenient and affordable, promote confidentiality and rapport with health care providers, and reduce stigma and discrimination. As such, the provision of SRH and HIV integrated services needs to be strengthened following different models of integration that are
  working successfully."
• There is a need to "develop programmes promoting the greater involvement of men in facility-based services as well as taking services closer to where men are (e.g. community outreach services and workplace services)."